Median nerve decompression for carpal tunnel syndrome — postoperative protocol

Management after isolated primary median nerve decompression for carpal tunnel syndrome, primarily using an open or mini-open approach. The goals are wound protection, preservation of finger and wrist motion, and a gradual return to effective hand use.

This protocol excludes nerve or tendon repair, tendon transfers and complex revision surgery. Concomitant procedures and complications require an individual plan. The same function-based progression principles apply after endoscopic release; a smaller incision does not automatically permit full loading.

No routine immobilisation. A cast, rigid wrist orthosis or sling is not routinely required. A soft dressing protects the wound and leaves the fingers free. Individual surgical instructions take precedence.

Movement from the day of surgery. Active finger and thumb movement and gentle wrist motion within comfort. Until the anaesthetic wears off, protect the hand from injury and burns and do not use it to carry objects.

Gradual loading. Initially avoid forceful gripping, heavy lifting and leaning on the operated palm. Timings are approximate; progression requires assessment of the wound, pain, swelling and grip control.

Fingers: gently straighten fully and bend into a loose fist. Start with 5–10 repetitions, 3–5 times daily. Do not squeeze with maximal force.

Thumb: touch each fingertip in turn and return to relaxed extension; repeat 5 times, 3–5 times daily. Do not force the end position.

Wrist: with the forearm supported, gently bend and extend actively without pushing with the other hand. Perform 5–10 repetitions, 3–5 times daily, if the dressing allows and the wound is not tensioned.

Adjust dosage to tolerance. Exercises should not increase numbness, swelling or pain that persists afterwards. Routine ball squeezing, aggressive nerve stretching and routine neurodynamic exercises are not required.

Swimming: usually around weeks 2–3, only when the wound is fully closed with no drainage or scabs. Start gently and increase effort according to tolerance.

Outdoor cycling: usually weeks 4–6. Requires tolerance of handlebar pressure, secure grip and effective braking. Delay return if there is pain at the base of the palm.

Gym exercise loading the hand, push-ups and weight-bearing: progressively during weeks 6–12, after meeting functional criteria. Racquet sports, climbing and contact sports also require tolerance of forceful gripping, rapid reactions and sport-specific loads; do not clear participation on time alone.

Progress to higher loads when the wound has healed, swelling is minimal or absent, movement is functional and grip is secure. A trial of the task must not cause significant pain, increasing paraesthesia or deterioration persisting the next day.

Full activity requires safe performance of the relevant work or sporting tasks. Complete resolution of pre-existing numbness is not essential if function is adequate, but sensory loss must be considered when handling hot, sharp or heavy objects.

Supervised hand therapy is not routinely necessary. Consider it for persistent stiffness, swelling, scar hypersensitivity or difficulty recovering function, after assessing the cause.

Everyday function usually improves substantially within 2–4 weeks. Recovery of grip strength and tolerance of higher loads often takes 6–12 weeks, sometimes several months.

Pain at the base of the palm on either side of the scar, known as pillar pain, may limit forceful gripping and weight-bearing despite normal wound healing. It often settles within approximately 3 months but can last longer.

Night pain and tingling may improve quickly. Constant numbness and muscle weakness associated with advanced neuropathy recover more slowly, over 6–12 months or longer, and recovery may remain incomplete. Absent improvement or worsening symptoms requires reassessment; time alone does not determine the success of decompression.

Keep the dressing clean and dry. Follow the orthopaedic surgeon’s dressing instructions. Elevate the hand above heart level intermittently when swollen, especially during the first few days. Also move the elbow and shoulder.

Once the anaesthetic has worn off, use the hand for light self-care such as eating, dressing and using a phone. Start typing and writing in short periods with breaks; avoid pressing the wound against a desk.

Do not soak the wound, clench the fist forcefully or support body weight on the palm. Wound review and removal of non-absorbable sutures are usually arranged at 10–14 days, as assessed by the surgeon. Suture removal alone does not indicate readiness for heavy loading.

Gradually increase use of the operated hand in light household tasks and work. Aim for comfortable finger extension, a full loose fist and functional wrist movement.

Once the wound is completely closed, with no drainage or scabs, begin gentle scar care and mobilisation if needed. For hypersensitivity, introduce graded exposure to touch. Do not massage an open wound or apply painful deep pressure.

Light grip resistance exercises may usually begin in weeks 3–4 if the wound has healed and everyday hand use is well tolerated. They are not mandatory. If needed, start with one short set of 8–10 repetitions using light resistance every other day, without maximal squeezing.

Weeks 4–6: gradually resume stronger gripping and heavier tasks. First increase the duration of light activity, then resistance. Introduce heavy loads and vibrating tools preferably from week 6, if hand function and tolerance allow.

Weeks 6–12: gradually resume gym exercise, weight-bearing through the hand and tasks involving greater palm pressure. Do not lean on the hand through pain. Introduce push-ups and heavy weights only after regaining tolerance of pressure, a secure grip and movement control.

If loading causes persistent pain, increased tingling or swelling, return to the previously tolerated level. Do not increase the load again until symptoms return to baseline.